Provider Demographics
NPI:1760850523
Name:WALL, GARY
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:WALL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:SCOTT
Other - Middle Name:
Other - Last Name:WALL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:780 S 2000 W STE F2
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:UT
Mailing Address - Zip Code:84075-9609
Mailing Address - Country:US
Mailing Address - Phone:801-776-8176
Mailing Address - Fax:
Practice Address - Street 1:780 S 2000 W STE F2
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:UT
Practice Address - Zip Code:84075-9609
Practice Address - Country:US
Practice Address - Phone:801-776-8176
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-10
Last Update Date:2015-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2664021223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry